Ophthalmology and Dermatology
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Hospitalization Consent Form
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Address Line 1
Address Line 2
District of Columbia
Name of Patient
I certify that I own/have assumed financial responsibility for the above-described animal. I do hereby consent and authorize the St. Georges Veterinary Hospital and its staff to hospitalize this animal, and to administer vaccinations, medications, tests, surgical procedures, anesthetics or treatments that the doctors deem necessary for the health, safety, or well-being of the above animal while it is under their care and supervision. Veterinary services during nighttime hours, and/or weekends, are provided at the discretion of the veterinarian in charge. Continuous presence of personnel may not be provided during these hours. If the animal should injure itself in an escape attempt, refuse food, soil itself, become ill, or die while in the hospital, I will hold the St. Georges Veterinary Hospital free of any responsibility and/or liability in the absence of gross negligence. I further realize that I am responsible for the payment of the above procedures and treatments in full at the time the animal is discharged. If I neglect to pick up the animal within five (5) days of written notice, which is mailed to the above address, that the pet is ready for release, you may assume that the pet is abandoned. In cases of abandonment, I understand that St. Georges Veterinary Hospital is authorized to dispose of the animal as they see fit. Abandonment does not release me of my obligation for the bill. I further agree that in the case of non-payment, a finance charge of 1.50% per month (18.00% per annum) will be charged and that any collection or attorney fees will be paid by me.
Telephone number where you can be reached:
Today, information regarding the HomeAgain chip has been explained to me upon admission of my pet. I understand that it is a microchip which is implanted in-between my pet’s shoulder blades, while under anesthesia, and which also carries an identification number unique to my pet. In the event my pet is lost or stolen, he/she can be traced back to me, provided the chip has been registered with the HomeAgain Pet Recovery Service.
Yes, please microchip the above mentioned pet.
No, please DO NOT microchip the above mentioned pet.